Speakers:

Dr Steve Collins, VALID International,
Andre Briend, World Health Organisation

Chair:

Lola Gostelow, Save the Children UK

Frances Mason, Save the Children UK

Ready to Use Therapeutic Food (RUTF) provides the cornerstone of the CTC approach. André Briend from WHO provided a comprehensive and provocative account of the history of RUTF, and of its significance in the shift towards community-based approaches to severe malnutrition.

Evidence has existed since the 1960s that hospital-based approaches to the management of severe malnutrition are very problematic. They tend to be limited in terms of their coverage, expose patients to a high risk of infection and consume high levels of scarce healthcare sources.

André Briend

A major constraint to moving towards community-based approaches was the fact that the food used, the milk-based F100 formula, required clinically controlled conditions for safe preparation. Also, distribution of powdered F100, which resembles infant formula, may undermine current efforts to promote breastfeeding. The development of RUTF, has provided a safe alternative to F100, in the form of a high calorie spread.

While RUTF provided the hard, nutritional input required to move the treatment of severe malnutrition out into the community, Dr Briend pointed out that this technical innovation was not sufficient to reach a large number of children and to have a public health impact, unless the approach used to treat severe malnutrition was also changed. In particular, what was needed was an effective mechanism for identifying severely malnourished children in the community and to ensure RUTF distribution at the community level. And it is here that the CTC approach, developed by Valid International, has come in.

Dr Steve Collins

CTC provides the 'software' that has translated RUTF into a useable tool for home based care. Steve Collins, Valid International, described the CTC approach. CTC confronts the tough operational and ethical challenges facing those responsible for treating severe malnutrition.

In particular, it tries to square the difficult circle as to how to maximise the quality of care, whilst also ensuring high coverage in very poor countries.

It does so first by differentiating between people who are severely malnourished, but otherwise not ill, and those suffering from complications. Under the CTC approach, the latter are referred to inpatient stabilisation centres. The former, however, are not admitted as in-patients, but are given RUTF which can be used at home.

Central to the approach is the mobilisation of the communities to take responsibility for case finding and follow-up of the acutely malnourished. In a range of contexts CTC programmes over the past 3 years have clearly demonstrated that, even in the face of an emergency and coexistent social upheaval, community structures and resources still exist and represent an indispensable resource that humanitarian agencies must work with, if they are to maximise the impact of their interventions.

This approach has been tried and tested in many countries around the world, with over 10,000 people. The results (detailed in full in the HPN paper and summarised in Dr Collins' presentation) are remarkable. The coverage rates attained by these programmes (typically around 70% even in remote rural communities) are many times greater than those achieved by centre-based approaches. In addition, amongst those accessing treatment, mortality and default rates are lower, while recovery rates are higher, than standard TFC approaches.

Both speakers outlined the challenges ahead. WHO will organise in November 2005 a consultation of experts to review whether and how RUTF and CTC approaches should become the standard approach to the treatment of severe malnutrition. Definition of clear guiding principles will be important if the benefits of CTC recorded in this initial pilot stage are to be sustained. There is a risk that without rigorous adherence to internationally agreed protocols, the efficacy of CTC will be diminished. Donor organisations are likely to have a critical role to play in ensuring that only experienced and professional organisations receive their financial support for CTC work.

 Discussion

The discussion following the meeting was wide ranging. There were different views regarding whether and how the necessary involvement from communities could be garnered and sustained in acute emergencies. The need to adopt flexible approaches, tailored to the needs, cultures and capacities of different communities and public health systems was also discussed. This in turn will demand adjusting the profile of staff away from one dominated by medical personnel, to one that includes people experienced in social and economic analysis.

The demands of applying CTC in situations of acute emergencies were also discussed, and specifically the perceived trade-offs implied between maximising coverage and providing rapid inputs. As the use of CTC expands, so issues of how to sustain inputs will need to be addressed.

In part, this is an issue of mainstreaming CTC and the use of RUTF into the public health system. In Malawi, for example, the government in now purchasing RUTF through the health budget, and there are on-going discussions regarding its inclusion in essential drugs provision.

In summarising the meeting, Frances Mason concluded that CTC was a major step forward in public health and nutrition. As an approach it had now gained great credibility, but was now at a crossroads. Important will be to make sure that in scaling up the applications of CTC and using it in new contexts, such as with populations with advanced AIDS, the same rigour continues to be applied and so its efficacy is sustained. After 40 years in the making, home-based approaches to severe malnutrition are at last in sight.